Evaluation of clinical outcomes in anterior cruciate ligament surgery

Clinical outcomes data can be used to facilitate patient management decisions, assess clinician and organizational performance, and to provide evidence for the effectiveness of surgery and rehabilitation. The validity of the inferences made from outcomes data are dependent on the validity of the outcomes measures themselves and the circumstances under which the data were collected, analyzed, and interpreted. Clinical outcomes may include measures of impairment of body structure and function, activity limitation, and participation restriction. However, because the relationship between impairment and the resulting activity limitation and participation restriction is not direct, and because activity limitations and participation restrictions are of the utmost concern to the athlete, the primary clinical outcome should be measures of activity limitation and participation restriction. Activity limitation and participation restriction may be measured either through direct observation of performance or by general or specific measures of health related quality of life. Clinical outcomes data must be collected systematically to ensure valid inferences from the data.     

Initial report of the use of an injectable porcine collagen-derived matrix to stimulate healing of diabetic foot wounds in humans

A novel injectable scaffolding matrix (E-Matrix) has been developed to accelerate wound healing in diabetic foot ulcers. This porcine collagen-derived matrix is designed to mimic tertiary embryonic connective tissue and to stimulate fetal wound repair mechanisms including angiogenesis. In vitro and animal studies have indicated a beneficial effect on tissue growth and an acceptable safety profile. In this report, we describe the initial use of this product in a pilot study of six humans with chronic nonhealing diabetic foot ulcers. A dramatic initial response to injection was seen, with an average wound size reduction of 72% 2 weeks after injection. Randomized trials are underway to define the potential benefit of this new treatment modality for diabetic foot ulcers.     

Advancement Flaps: A Basic Theme with Many Variations

Background. The advancement flap involves the linear advancement of tissue in one direction. Despite its straightforwardness and simple concept, it can be used to close a variety of defects, ranging from small defects on the scalp or extremities to large, complicated defects involving cosmetic units on the face.
Objectives. To provide a basic and useful review for the indications, advantages, disadvantages, and techniques for the use of advancement flaps in the reconstruction of defects in dermatologic surgery.
Materials and Methods. We performed a literature search for articles discussing advancement flaps and compiled a brief review of our findings.
Results. The movement of the advancement flap must be balanced by the blood supply of the flap. The excision of Burow's triangles along various aspects of the advancement flap can increase movement and improve cosmesis of the flap. The types of advancement flaps discussed include the single advancement flap, double advancement flap, A-T flap (O-T flap), Burow's triangle flap (Burow's wedge flap), crescenteric advancement flap, island pedicle flap (V-Y flap), helical rim advancement flap, and facelift flap.
Conclusion. Advancement flaps are versatile and useful basic flaps for repairing defects.     

Effects of Botulinum Toxin Type A on Contouring of the Lower Face

BACKGROUND: Masseteric muscle hypertrophy is an uncommon dition represented as a swelling of the masseter muscle. Recent reports have demonstrated the successful use of botulinum in the treatment of masseteric hypertrophy. OBJECTIVE: This study was a prospective trial to evaluate the effectiveness of botulinum toxin type A (Botox) in the treatment of masseteric muscle hypertrophy according to doses of 10, 20, and 30 U. MATERIALS AND METHODS: Twenty-two patients were referred to the dermatologic clinic for the management of masseteric muscle hypertrophy. Ultrasonographic measurements of the thickness of the masseter muscle were performed, and clinical photographs were taken before treatment and 1, 2, 3, 4, 6, and 9 months after the treatment. RESULTS. The median values of percentage reduction of muscle mass were 10.3%, 16.5%, 23.7%, 24.7%, 21.6%, 16.5% in the 10 U group; 11.9%, 18.8%, 24.8%, 27.7%, 26.7%, and 21.8% in the 20 U group; and 12.0%, 19.4%, 25.0%, 27.8%, 37.8%, and 24.1% in the 30 U group. CONCLUSION. The adequate dose of botulinum toxin type A for treatment of masseteric muscle hypertrophy should be above 20 U. The effect of botulinum toxin type A is maintained for at least 9 months as the treatment of masseteric muscle hypertrophy.     

Deep Phenol Peeling and Fat Injection: Treatment Option for Perioral Wrinkles in a Scleroderma Patient

Background Scleroderma is characterized by abnormal growth of connective tissue, often manifested with hard and tight skin. The viscous properties of the skin are impaired, and the main histologic changes include a thicker dermis, absence of pilosebaceous units, and a decreased space between collagen bundles. Often these patients have wound healing problems.
Objective The objective was to demonstrate a case of scleroderma that had deep phenol perioral peeling and fat injection into the lips. According to our bibliographic search, this is the first report in the English literature of using these modalities in scleroderma patients.
Methods A 64-year-old woman suffering from scleroderma for more than 20 years came for improvement of her perioral appearance. We decided to manage her deep perioral wrinkles by deep peeling using the Baker formula and concomitantly to use autologous fat injection to augment her thin lips.
Results The healing of our patient after these two interventions was uneventful, and satisfactory results have been obtained.
Conclusion Based on our experience, this intervention may be suggested for patients suffering from scleroderma after a detailed explanation of the possible wound healing difficulties is provided to the patients.     

Cosmeceuticals Containing Herbs: Fact, Fiction, and Future

Background. Modern medicine is rooted in ethnobotanical traditions using indigenous flora to treat symptoms of human diseases or to improve specific aspects of the body condition. Herbal medicine is now used by over half of the American population. Yet the American medical community generally lacks knowledge of the function, metabolism, interaction, adverse reactions, and preparation of herbal products.
Objective. Because over 60 botanicals are marketed in cosmeceutical formulations, dermatologists need to obtain working knowledge of the major botanicals. The preparation, traditional uses, mechanisms of action, human clinical data, adverse reactions, and interactions all impact herbal efficacy and are discussed below.
Method. English-language medical journal and symposium searches.
Results. The most important botanicals pertaining to dermatologic uses, such as cosmeceuticals, include teas, soy, pomegranate, date, grape seed, Pycnogenol, horse chestnut, German chamomile, curcumin, comfrey, allantoin, and aloe. All are documented to treat dermatologic conditions. Only green and black tea, soy, pomegranate, and date have published clinical trials for the treatment of parameters of extrinsic aging.
Conclusions. Preparation of botanical-based cosmeceuticals is complex. Very few of these products are supported by evidence-based science.
CARL THORNFELDT, MD, FAAD, HAS INDICATED NO SIGNIFICANT INTEREST WITH COMMERCIAL SUPPORTERS.     

乳头溢液的外科治疗（附207例分析）

目的探讨乳头溢液的渗断和治疗方法，为合理的治疗提供科学依据。方法回顾分析手术治疗的207例乳头溢液病例资料。结果（1）在非哺乳期间发生乳头溢液多属病理性溢液；（2）通过美蓝法或平针头指示法行区段切除术，安全准确。结论（1）乳头溢液特别足血性溢液应手术治疗．对早期发现和早期治疗乳腺癌有鼋要的临床意义。（2）乳头溢液伴肿块者，不沧年龄大小、溢液性质均应手术治疗。     

Inguinal hernia repair in Hospital Authority hospitals: The role of laparoscopic hernioplasty

Objective: Two major changes have occurred in inguinal hernia repair during the last two decades: (i) the use of tension‐free mesh repair; and (ii) the application of laparoscopic technique for repair. The aims of the present study were to study: (i) how inguinal hernia repair was carried out; and (ii) the outcome of inguinal hernia repair in Hospital Authority (HA) hospitals. Methodology: This was a retrospective analysis on 8311 elective inguinal hernia repairs performed in 16 HA hospitals from January 2001 to December 2003. The mean age was 63.9 ± 14.2 years, and the male to female ratio was 22.0 : 1.0. Among these, 869 (10.5%) repairs were performed with the laparoscopic approach and 7442 (89.5%) repairs with the open approach. The proportion of laparoscopic hernia repair increased from 8.7% to 12.6%. Results: For open repair, 39% of cases were carried out with regional anaesthesia, 32% with general anaesthesia and 29% with local anaesthesia (LA). Furthermore, mesh repair was used in 88% of the patients. For laparosocpic repair, 98.4% of cases were carried out under general anaesthesia, and all patients had mesh repair using the totally extraperitoneal approach. A significantly higher proportion of bilateral repair and recurrent hernia repair was performed with the laparoscopic approach (P = 0.000). For primary unilateral repair, there was no significant difference in the postoperative length of stay (LOS) and the total LOS between the laparoscopic and the open surgery groups. No difference in LOS was found in recurrent hernia repair between the two groups. With respect to bilateral repair, both the preoperative LOS (P = 0.036) and total LOS (P = 0.039) were shorter in the laparoscopic group. Furthermore, a significantly higher proportion of day‐surgery patients was observed in the laparoscopic group than the open surgery group (21.3%vs 16.9%, P = 0.001). Nevertheless, when only the results of 2003 were analyzed, the postoperative LOS (P = 0.000) and total LOS (P = 0.000) were significantly shorter in the laparoscopic group than the open surgery group. The LOS parameters were significantly shorter in the open surgery LA subgroup compared with the non‐LA subgroup (P = 0.000), and they were not different from those in the laparoscopic group. Conclusions: The open mesh repair is the predominant approach for inguinal hernia repair in HA hospitals. The originally described local anaesthetic approach was under utilized, although it resulted in good outcome. The use of laparoscopic hernia repair is increasing and a learning curve was recently observed with improved outcome.     

Guidelines for Trials of Behavioral Treatments for Recurrent Headache, First Edition: American Headache Society Behavioral Clinical Trials Workgroup

Guidelines for design of clinical trials evaluating behavioral headache treatments were developed to facilitate production of quality research evaluating behavioral therapies for management of primary headache disorders. These guidelines were produced by a Workgroup of headache researchers under auspices of the American Headache Society. The guidelines are complementary to and modeled after guidelines for pharmacological trials published by the International Headache Society, but they address methodologic considerations unique to behavioral and other nonpharmacological treatments. Explicit guidelines for evaluating behavioral headache therapies are needed as the optimal methodology for behavioral (and other nonpharmacologic) trials necessarily differs from the preferred methodology for drug trials. In addition, trials comparing and integrating drug and behavioral therapies present methodological challenges not addressed by guidelines for pharmacologic research. These guidelines address patient selection, trial design for behavioral treatments and for comparisons across multiple treatment modalities (eg, behavioral vs pharmacologic), evaluation of results, and research ethics. Although developed specifically for behavioral therapies, the guidelines may apply to the design of clinical trials evaluating many forms of nonpharmacologic therapies for headache.